GW1-2022-04159_Well Construction - GW1_20220425

WELL CONSTRUCTION CTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Infforrmmaatio`u: 14.{
eta//� 6�✓�[`J Z ffr- 1/ �L�C ff FROM WATER TTOiVES DESCRIPTION
Well Contractor Name ft. ft. /- o
a 036 ft. fL va
NC Well Contractor Certification Number 15.OUTER (for multi-eased wells'OR'LINER{if n '[icablc
M / / G� FROM TO DIAMETER THICKNESS h1ATEli1AL
(/ � �in. e ;)--I Y
Company Name 16.INNER CASING OR TUBING '66thermal closed-loop)::
3 / `� /'� FROM ft.
DIAMETER TIHCKNESS MATERIAL
2.Well Construction Permit#: /S / '7 CJ ft. ft. in.
List all applicable well construction peiinlits(i.e.Cot 1 Stare.Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN.
Water Supply Well: FROMi I TO DIAb1ETER SLOT SIZE TIHCICNESS MIATERiAL
❑Agriculhtral ❑Muni^cipaU ft. ft. in.
Public
❑Geothermal(Heating/Cooling Supply) 2</idential Water Supply(single) ft. ft. !n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROMI TO MATERIAL EMPLACE:IIENT METHOD&AMOUNT
❑Ifni anion ft. ft. ./r d u
Non-Water Supply Well: r17 ft. ft.
[]Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation . 19.SAND/GRAVEL PACK tf a 'rlicable) -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACE1rEiV7 METHOD' ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. fG
❑I xperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets ifn&essa )
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sallrruck c,grain slzc,etc.)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) ur ft. U ft. �' ILL t.
2 CL O ft. C t
4.Date Well(s)Completed: ._r � �/
`\ ft. ft. Let
ell Loc
a
-/ `� C Q ft ft
cv" aY�Q1z J ft ru
Facility/Owner Name Facility ID#(if applicable)
/��y�j'� y� fL ft.
a3 f Q sue/�'1ac L /� ��I ft. ft. APR 202!
Physical Address City,and Zip .21.REIVIARI(S
County Parcel Identification No.(PIN) ,,,,;:ii ti +t ,J J�•M
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Ifwell field one lat/lon issufficient)3.5, sir 0 7 l N 4 0. 8 g 1-l.31 3 W /V-"
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 6r3' ee'rmanent or ❑Temporary By signing this form. i hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C_0100 a)-15.1 NCAC 02C.0200 Well Costructior Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provided to the well owner.
40his is a repair,fill out known well construction information and explain the nature ofthe
repair tinder ft2l remarks section or on the back of thisforo• 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
i or multiple infection or non-water supply wells ONLY with the saute constritciiwn,you can
submit onefonn. 24.Submittal Instructions:
9.Total well depth below land surface: � &0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
!tor•multiple wells list all depths ifdii erew(arannple-3©200'and 2Q10n construction to the following:
10.Static water level below top of casing: .3 5 (ft.) Division of Water Quality,Information Processing Unit,
r 1J'water level is above casing•use"+" 1637 Mail Servic i e Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Inieetion Wells: In addition to sending the form to the address in 24a
/� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /l D�Gi i c/ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/ r 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) / 141ethod of test: / the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
]3b.Disinfection type: Amount: where constructed.
i
Fonn GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013